Approach to Depression in Patients with Brain Diseases: Stroke, Parkinson’s Disease, and Dementia

  • Kyung Bong Koh


The physical and/or psychological sequelae caused by stroke, Parkinson’s disease, and dementia may be devastating for both the patient and family. Depression during these illnesses not only complicates diagnosis and treatment but also hinders therapeutic efforts. SSRIs and tricyclic antidepressants are known to be effective in poststroke depression. These antidepressants should be continued at least for 4 months after initial recovery and should be changed if no response is seen after 6 weeks. Psychotherapy including cognitive behavioral therapy can be tried for patients with milder depression and those with side effects or contraindications to the use of antidepressants. Multidisciplinary and integrative approaches are recommended for assessing and treating poststroke depression. Tricyclic antidepressants as well as bupropion and SSRIs help improve depression in patients with Parkinson’s disease. However, bupropion, SSRIs, and venlafaxine are preferred drugs for depressed patients with dementia because they cause less cognitive impairment and sedative action than tricyclic antidepressants. Overall, therapeutic approaches to Parkinson’s disease or dementia comorbid with depression may involve a combination of psychopharmacological treatment and psychotherapeutic interventions including behavioral treatment.


Stroke Parkinson’s disease Dementia Depression Mechanisms of poststroke depression Integrative approach Multidisciplinary approach Psychopharmacotherapy Psychotherapy 


  1. 1.
    Whyte EM, Mulsant BH. Post-stroke depression: epidemiology, pathophysiology, and biological treatment. Biol Psychiatry. 2002;52:253–64.PubMedGoogle Scholar
  2. 2.
    Robinson RG, Spalletta G. Poststroke depression: a review. Can J Psychiatr. 2010;55:341–9.Google Scholar
  3. 3.
    Robinson RG. Neuropsychiatric consequences of stroke. Annu Rev Med. 1997;48:217–29.PubMedGoogle Scholar
  4. 4.
    Wolfe CDA. The impact of stroke. Br Med Bull. 2000;56:275–86.PubMedGoogle Scholar
  5. 5.
    Williams LS, Ghose SS, Swindle RW. Depression and other mental health diagnoses increase mortality risk after ischemic stroke. Am J Psychiatry. 2004;161:1090–5.PubMedGoogle Scholar
  6. 6.
    Hackett M, Anderson C. Treatment options for post-stroke depression in the elderly. Aging Health. 2005;1:95–105.Google Scholar
  7. 7.
    Murphy E. Social origins of depression in old age. Br J Psychiatry. 1982;141:134–42.Google Scholar
  8. 8.
    De Ryck A, Brouns R, Fransen E, et al. A prospective study on the prevalence and risk factors of poststroke depression. Cerebrovasc Dis Extra. 2013;3:1–13.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Cohen-Cole SA, Harpe C. Assessment of depression in the medically ill. In: Stoudemire A, Fogel BS, editors. Principles of medical psychiatry. Orlando: Grune & Stratton; 1987.Google Scholar
  10. 10.
    Cassem NH. Depression. In: Cassem NH, editor. MGH handbook of general hospital psychiatry. St. Louis: Mosby-Year Book; 1991.Google Scholar
  11. 11.
    Lenze E, Rogers J, Martire L, et al. The association of late-life depression and anxiety with physical disability: a review of the literature and prospectus for future research. Am J Geriatr Psychiatry. 2001;9:113–35.PubMedGoogle Scholar
  12. 12.
    Austin M, Mitchell P, Goodwin G. Cognitive deficits in depression: possible implications for functional neuropathology. Br J Psychiatry. 2001;178:200–6.PubMedGoogle Scholar
  13. 13.
    Butters M, Becker J, Nebes R, et al. Changes in cognitive functioning following treatment of late-life depression. Am J Psychiatry. 2000;157:1949–54.PubMedGoogle Scholar
  14. 14.
    Gillen RTH, McKee TE, Gernert-Dott P, et al. Depressive symptoms and history of depression predict rehabilitation efficiency in stroke patients. Arch Phys Med Rehabil. 2001;82:1645–9.PubMedGoogle Scholar
  15. 15.
    Paolucci S, Antonucci G, Grasso M, et al. Poststroke depression, antidepressant treatment and rehabilitation results: a case-controlled study. Cerebrovasc Dis. 2001;12:264–71.PubMedGoogle Scholar
  16. 16.
    Schulz R, Beach S, Ives D, et al. Association between depression and mortality in older adults: The Cardiovascular Health Study. Arch Intern Med. 2000;160:1761–8.PubMedGoogle Scholar
  17. 17.
    Ensinck K, Schuurman A, van den Akker M, et al. Is there an increased risk of dying after depression? Am J Epidemiol. 2002;156:1043–8.PubMedGoogle Scholar
  18. 18.
    Glassman A, Shapiro P. Depression and the course of coronary artery disease. Am J Psychiatry. 1998;155:4–11.PubMedGoogle Scholar
  19. 19.
    Rabins P. Barriers to diagnosis and treatment of depression in elderly patients. Am J Geriatr Psychiatry. 1996;4:79–83.Google Scholar
  20. 20.
    Schubert D, Taylor C, Lee S, et al. Detection of depression in the stroke patient. Psychosomatics. 1992;33:290–4.PubMedGoogle Scholar
  21. 21.
    Christensen H, Jorm A, Mackinnon A, et al. Age differences in depression and anxiety symptoms: a structural equation modeling analysis of data from a general population sample. Psychol Med. 1999;29:325–39.PubMedGoogle Scholar
  22. 22.
    Meader N, Moe-Byrne T, Llewellyn A, et al. Screening for poststroke major depression: a meta-analysis of diagnostic validity studies. J Neurol Neurosurg Psychiatry. 2014;85:198–206.PubMedGoogle Scholar
  23. 23.
    Agrell B, Dehlin O. Comparison of six depression rating scales in geriatric stroke patients. Stroke. 1989;20:1190–4.PubMedGoogle Scholar
  24. 24.
    Carod-Artal F, Ferreira Coral L, Trizotto D, et al. Poststroke depression: prevalence and determinants in Brazilian stroke patients. Cerebrovasc Dis. 2009;28:157–65.PubMedGoogle Scholar
  25. 25.
    Strober LB, Arnett PA. Assessment of depression in three medically ill, elderly populations: Alzheimer’s disease, Parkinson’s disease, and stroke. Clin Neuropsychol. 2009;23:205–30.PubMedGoogle Scholar
  26. 26.
    Laidlaw K. Poststroke depression and CBT with older people. In: Dolores G-T, Ann MS, Lary WT, editors. Handbook of behavioral and cognitive therapies with older adults. New York: Springer; 2007.Google Scholar
  27. 27.
    Alexopoulos G, Buckwalter K, Olin J, et al. Comorbidity of late life depression: an opportunity for research on mechanisms and treatment. Biol Psychiatry. 2002;52:543–58.PubMedGoogle Scholar
  28. 28.
    Lokk J, Delbari A. Management of depression in elderly stroke patients. Neuropsychiatr Dis Treat. 2010;6:539–49.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Gusev E, Bogolepova A. Depressive disorders in stroke patients. Neurosci Behav Physiol. 2009;39:639–43.PubMedGoogle Scholar
  30. 30.
    Chen Y, Guo JJ, Zhan S, et al. Treatment effects of antidepressants in patients with post-stroke depression: a meta-analysis. Ann Pharmacother. 2006;40:2115–22.PubMedGoogle Scholar
  31. 31.
    Starkstein SE, Mizrahi R, Power BD. Antidepressant therapy in post-stroke depression. Expert Opin Pharmacother. 2008;9:1291–8.PubMedGoogle Scholar
  32. 32.
    Cunningham LA. Depression in the medically ill: choosing an antidepressant. J Clin Psychiatry. 1994;55(Suppl AJ):90–7.PubMedGoogle Scholar
  33. 33.
    Snow V, Lascher S, Mottur-Pilson C. Pharmacologic treatment of acute major depression and dysthymia: clinical guideline, part 1. Ann Intern Med. 2000;132:738–42.PubMedGoogle Scholar
  34. 34.
    Turner-stokes L, Hassan N. Depression after stroke: a review of the evidence base to inform the development of an integrated pathway. Part 1: diagnosis, frequency and impact. Clin Rehabil. 2002;16:231–47.PubMedGoogle Scholar
  35. 35.
    Williams LS. Depression and stroke: cause or consequence? Semin Neurol. 2005;25:396–409.PubMedGoogle Scholar
  36. 36.
    Paolucci S. Epidemiology and treatment of post-stroke depression. Neuropsychiatr Dis Treat. 2008;4:145–54.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Scogin F, Welsh D, Hanson A, et al. Evidence-based psychotherapies for depression in older adults. Clin Psychol Sci Pract. 2006;12:222–37.Google Scholar
  38. 38.
    Watkins C, Auton M, Deans C, et al. Motivational interviewing early after acute stroke: a randomized, controlled trial. Stroke. 2007;38:1004–9.PubMedGoogle Scholar
  39. 39.
    Gallagher-Thompson D, Steffen A, Thompson L, et al. Handbook of behavioral and cognitive therapies with older adults. New York: Springer; 2008.Google Scholar
  40. 40.
    Gebretsadik M, Jayaprabhu S, Grossberg G. Mood disorders in the elderly. Med Clin North Am. 2006;90:789–805.PubMedGoogle Scholar
  41. 41.
    Lincoln N, Flannaghan T. Cognitive behavioral psychotherapy for depression following stroke: a randomized controlled trial. Stroke. 2003;34:111–5.PubMedGoogle Scholar
  42. 42.
    Hackett M, Anderson C, House A. Interventions for treating depression after stroke. Stroke. 2009;40:e487–e8.Google Scholar
  43. 43.
    Australian R. Australian and new Zealand clinical practice guidelines for the treatment of depression. Aust N Z J Psychiatry. 2004;38:389–407.Google Scholar
  44. 44.
    Lai SM, Studenski S, Richards L, et al. Therapeutic exercise and depressive symptoms after stroke. J Am Geriatr Soc. 2006;54:240–7.PubMedGoogle Scholar
  45. 45.
    Fiske A, Wetherell J, Gatz M. Depression in older adults. Ann Rev Clin Psychol. 2009;5:363–89.Google Scholar
  46. 46.
    Turner-Stokes L, Hassan N, et al. Managing depression in brain injury rehabilitation: the use of an integrated care pathway and preliminary report of response to sertraline. Clin Rehabil. 2002;16:261–8.PubMedGoogle Scholar
  47. 47.
    Beck AT, Ward CH, Mendelssohn MJ, et al. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561–71.PubMedPubMedCentralGoogle Scholar
  48. 48.
    Gordon WA, Hibbard MR, Egelko S, et al. Issues in the diagnosis of post-stroke depression. Rehabil Psychol. 1991;36:71–87.Google Scholar
  49. 49.
    Sutcliffe LM, Lincoln NB. The assessment of depression in aphasic stroke patients: the development of the Stroke Aphasic Depression Questionnaire. Clin Rehabil. 1998;12:506–13.PubMedGoogle Scholar
  50. 50.
    Koh KB. Poststroke depression: mechanisms and management. In: Koh KB, editor. Somatization and psychosomatic symptoms. New York: Springer; 2013.Google Scholar
  51. 51.
    McNamara ME. Neurology. In: Stoudemire A, Fogel BS, editors. Principles of medical psychiatry. Orlando: Grune & Stratton; 1987.Google Scholar
  52. 52.
    Mayeux R, Stern Y, Cote L. Altered serotonin metabolism in depressed patients with Parkinson’s disease. Neurology. 1984;34:642–6.PubMedGoogle Scholar
  53. 53.
    Mayeux R, Stern Y, Williams JB. Clinical and biochemical features of depression in Parkinson’s disease. Am J Psychiatry. 1986;143:756–9.PubMedGoogle Scholar
  54. 54.
    Wen MC, Chan LL, Tan LC, et al. Depression, anxiety, and apathy in Parkinson’s disease: insights from neuroimaging studies. Eur J Neurol. 2016;23:1001–19.PubMedGoogle Scholar
  55. 55.
    Goodarzi Z, Mrklas KJ, Roberts DJ, et al. Detecting depression in Parkinson disease: a systematic review and meta-analysis. Neurology. 2016;87:426–37.PubMedPubMedCentralGoogle Scholar
  56. 56.
    Torbey E, Pachana NA, Dissanayaka NN. Depression rating scales in Parkinson's disease: a critical review updating recent literature. J Affect Disord. 2015;184:216–24.PubMedGoogle Scholar
  57. 57.
    Cummings JL. Depression and Parkinson’s disease: a review. Am J Psychiatry. 1992;149:443–54.PubMedGoogle Scholar
  58. 58.
    Goetz CG, Tanner CM, Klawans HL. Bupropion in Parkinson’s disease. Neurology. 1984;34:1092–4.PubMedGoogle Scholar
  59. 59.
    Bouchard RH, Pourcher E, Vincent P. Fluoxetine and extrapyramidal side effects [letter]. Am J Psychiatry. 1989;146:1352–3.Google Scholar
  60. 60.
    Meltzer HY, Young M, Metz J. Extrapyramidal side effects and increased serum prolactin following fluoxetine, a new antidepressant. J Neural Transm. 1979;45:165–75.PubMedGoogle Scholar
  61. 61.
    Yang S, Sajatovic M, Walter BL. Psychosocial interventions for depression and anxiety in Parkinson’s disease. J Geriatr Psychiatry Neurol. 2012;25:113–21.PubMedGoogle Scholar
  62. 62.
    Armento ME, Stanley MA, Marsh L, et al. Cognitive behavioral therapy for depression and anxiety in Parkinson’s disease: a critical review. J Parkinsons Dis. 2012;2:135–51.PubMedGoogle Scholar
  63. 63.
    Egan SJ, Laidlaw K, Starkstein S. Cognitive behavioral therapy for depression and anxiety in Parkinson’s disease. J Parkinsons Dis. 2015;5:443–51.PubMedPubMedCentralGoogle Scholar
  64. 64.
    Quelhas R. Psychiatric care in Parkinson’s disease. J Psychiatr Pract. 2013;19:118–41.PubMedGoogle Scholar
  65. 65.
    Slaby AE, Cullem LO. Dementia and delirium. In: Stoudemire A, Fogel BS, editors. Principles of medical psychiatry. Orlando: Grune & Stratton; 1987.Google Scholar
  66. 66.
    McCarthy JR, Palmateer LM. Assessment of cognitive deficit in geriatric patients: a study of physician behavior. J Am Geriatr Soc. 1985;33:467–71.Google Scholar
  67. 67.
    Doody RS, Stevens JC, Beck C, et al. Practice parameter: management of dementia(an evidence based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56:1154–66.PubMedGoogle Scholar
  68. 68.
    Lyketsos CG, Olin JT. Depression in Alzheimer disease: overview and treatment. Biol Psychiatry. 2002;52:243–52.PubMedGoogle Scholar
  69. 69.
    Olin JT, Schneider LS, Katz IR, et al. National Institute of Mental Health-Provisional Diagnostic Criteria for Depression of Alzheimer Disease: rationale and background. Am J Geriatr Psychiatry. 2002;10:125–8.PubMedGoogle Scholar
  70. 70.
    Reifler BV, Larson E, Teri L. Dementia of the Alzheimer’s type and depression. J Am Geriatr Soc. 1986;34:855–9.PubMedGoogle Scholar
  71. 71.
    Lazarus LW, Newton N, Cohler B. Frequency and presentation of depressive symptoms in patients with primary degenerative dementia. Am J Psychiatry. 1987;144:41–5.PubMedGoogle Scholar
  72. 72.
    Burns A, Jacoby R, Levy R. Psychiatric phenomena in Alzheimer disease, III: disorders of mood. Br J Psychiatry. 1990;157:81–6.PubMedGoogle Scholar
  73. 73.
    Lyketsos CG, Steinberg M, Tschantz J, et al. Mental and behavioral disturbances in dementia: findings from the Cache County study on memory in aging. Am J Psychiatry. 2000;157:708–14.PubMedGoogle Scholar
  74. 74.
    Fischer P, Simanyi M, Danielczyk W. Depression in dementia of the Alzheimer type and in multi-infarct dementia. Am J Psychiatry. 1990;147:1484–7.PubMedGoogle Scholar
  75. 75.
    Reding M, Haycox J, Blass J. Depression in patients referred to a dementia clinic: a three year prospective study. Arch Neurol. 1985;42:894–6.PubMedGoogle Scholar
  76. 76.
    Katz IR. Diagnosis and treatment of depression in patients with Alzheimer’s disease and other dementia. J Clin Psychiatry. 1998;59(Suppl 9):38–44.PubMedGoogle Scholar
  77. 77.
    Goodarzi ZS, Mele BS, Roberts DJ, et al. Depression case finding in individuals with dementia: a systematic review and meta-analysis. J Am Geriatr Soc. 2017;65:937–48.PubMedGoogle Scholar
  78. 78.
    Conn D, Thorpe L. Assessment of behavioral and psychological symptoms associated with dementia. Can J Neurol Sci. 2007;34(Suppl 1):S67–71.PubMedGoogle Scholar
  79. 79.
    Gutzmann H, Qazi A. Depression associated with dementia. Z Gerontol Geriatr. 2015;48:305–11.PubMedGoogle Scholar
  80. 80.
    Bains J, Birks J, Denning T. Antidepressants for treating depression in dementia. Cochrane Database Syst Rev. 2002;21:CD003944.Google Scholar
  81. 81.
    Lyketsos CG, DelCampo L, Steinberg M, et al. Treating depression in Alzheimer disease: efficacy and safety of sertraline therapy, and the benefits of depression reduction: the DIADS. Arch Gen Psychiatry. 2003;60:737–46.PubMedGoogle Scholar
  82. 82.
    Raskind MA. The clinical interface of depression and dementia. J Clin Psychiatry. 1998;59(Suppl 10):9–12.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Kyung Bong Koh
    • 1
  1. 1.Department of PsychiatryYonsei University College of MedicineSeoulKorea

Personalised recommendations